- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,230.27 / $8,511.38
| Facility | | $1,174.90 | $1,230.27 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,230.27 / $1,778.28
| Professional | | $891.25 | $1,230.27 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,570.40 / $3,090.30
| Professional | | $2,089.30 | $2,570.40 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,238.72 / $3,630.78
| Professional | | $1,548.82 | $2,238.72 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,862.09 / $3,548.13
| Facility | | $1,174.90 | $1,862.09 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,089.30 / $2,570.40
| Professional | | $1,148.15 | $2,089.30 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,089.30 / $2,951.21
| Professional | | $1,148.15 | $2,089.30 | $2,951.21 |